Cardiovascular Conditions PDF

Vascular Category (Primary Cardiovascular System) Condition Name Varicose veins Definition/ Risk Factors Dilated superficial veins w/o valves or incompetent valves *pregnancy, prolonged immobilization, FHx, Obesity Notes Val...

Vascular Category (Primary Cardiovascular System) Condition Name Varicose veins Definition/ Risk Factors Dilated superficial veins w/o valves or incompetent valves *pregnancy, prolonged immobilization, FHx, Obesity Notes Valves cannot properly push blood against gravity, so blood starts pooling and dilating the vessels Symptoms Long tortuous and prominent superficial veins, mainly on the lower extremity Sense of fullness in the legs Ulcerations Hyperpigmentation Fatigue > with elevation < menses Investigations Lab test or PE Positive Sign Palpation Palpable superficial veins, blue colour, warm to touch Brodie Trendelenburg test Veins fill quickly when standing after supine compression and drainage (by elevating leg) Progressions/Sequalae if Recurring thrombophlebitis left untreated External or subcutaneous hemorrhaging Leg ulcerations Venous eczema Treatments Keep legs elevated to promote drainage Compression stockings Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Atherosclerosis Definition/ Risk Factors Thickening and hardening of the arteries d/t buildup of plaques that contain lipids, cholesterol, inflammatory and smooth muscle cells, and connective tissue *increasing age, M>F, repeated injuries to the arteries, FHx, DM, HTN, physical inactivity, hyperlipidemia, obesity, smoking Notes Most common cause of mortality in the US Inflammatory response of vessel to LDL → cholesterol deposits and plaque formation in the tunica intima of the vessel Symptoms Chest pain Light-headedness, dizziness, SOB, Palpitations = coronary artery Severe HA, difficulty speaking, walking, visual changes = carotid Numbness & pain = peripheral arteries Investigations Lab test or PE Positive Sign 1  Physical exam r/o secondary causes Angiography Assess plaque thickness Autopsy of arterioles Fatty streaks Ddx. PE, HTN Progressions/Sequalae if CAD, MI, Stroke, Aneurysm, Hemorrhage, PVD, Thrombosis/Embolism left untreated Treatments Avoid risk factors Diet Antiplatelet drugs (ASA) ACEi, Angiotensin II blockers, Statins Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Thrombosis Definition/ Risk Factors Development of blood clot within the blood vessel (attached to the endothelial walls of the vessel) *atherosclerosis, DIC, coagulation pathology Notes Caused by obstruction of blood flow Classifications: Venous Thrombosis - Deep vein thrombosis: blood clot, swelling, pain, erythema, commonly femoral vein - Portal vein thrombosis → portal hypertension - Renal Vein → reduced kidney function - Budd-Chiari syndrome: thrombus in inferior vena cava or hepatic vein → abd pain, hepatomegaly, ascites Arterial Thrombosis - Usually caused by an atheroma Symptoms Dependent on thrombus location *May be asymptomatic Local inflammation Dilated superficial veins Pain with palpation SOB w/ exercise (pulmonary embolism) Investigations Lab test or PE Positive Sign Physical exam Dependent on thrombus location Dopple U/S D-dimer lab for DVT, PE or DIC Assessing fibrinogen activation Ddx. Cellulitis, Lymphedema, Extrinsic compression by tumor or LN Progressions/Sequalae if Embolism (dislodging of thrombus) left untreated Thrombophlebitis: secondary/acute inflammation Phlebothrombosis: thrombosis without inflammation Stroke, MI (Arterial thrombosis) Pulmonary embolism (venous thrombosis) Treatments Anticoagulants Red flag? Refer? 2 Category (Primary Cardiovascular System) Condition Name Embolism Definition/ Risk Factors A particle (embolus) that moves through the arteries and veins risking occlusion, commonly made of a dislodged thrombus *HTN, Hyperlipidemia, Atherosclerosis, smoking, CAD, sedentary lifestyle Notes Classifications: - Pulmonary embolism (PE): invades the pulmonary circulation to occlude pulmonary perfusion - Air embolism: air bubble in arterial blood flow - Fat embolism: fat or bone marrow - Septic embolism: initial infection results in particles entering the bloodstream - Amniotic embolism: amniotic fluid entering maternal bloodstream (can lead to PE Symptoms Pain Tingling Numbness Coldness No pulse below blockage muscle spasm *severity of symptoms dependent on size of embolism Investigations Lab test or PE Positive Sign Peripheral pulses NO pulse below blockage Pulmonary angiogram Gold standard for PE Ventilation/perfusion scan (V/Q) To rule out developing PE Progressions/Sequalae if MI left untreated Pulmonary infarct Gangrene Treatments Anticoagulants Thrombolytic agents Red flag? Refer? Category (Primary Cardiovascular System) Condition Name Aneurysm Definition/ Risk Factors Dilation of 1 segment of an artery due to defect in tunica media of the vessel (weakening of the vessel walls) *Marfan’s, collagen disorder, smoking, FHx, HTN, atherosclerosis, tertiary syphilis, physical stress, M>F Notes May occur d/t poor perfusion of media of the vessel causing weakening and dilation of the vessel Common: - Abdominal 3  - Cerebral - Aortic Symptoms Abdominal Usually asymptomatic Steady lumbosacral pain (abdominal) Tender to palpation if rapidly enlarging Pulsating mass above the naval Aortic Back pain/ pressure on the ribs or vertebrae Tearing pain Cough & Wheezing Hemoptysis Dysphagia Hoarseness Abn chest pulsations Cerebral Usually asymptomatic until rupture Severe headache N/V Intraocular hemorrhage Meningismus Bilateral leg pain (blood in CSF) Investigations Lab test or PE Positive Sign Auscultation Pulsating mass, heart murmurs Palpation Tender on palpation CT Confirm ballooning of vessel Lumbar puncture Blood in CSF Angiography Ballooning of vessel, pooling of fluid Ddx. Constipation, syphilis, infection, laryngitis, lung tumor, headache, Progressions/Sequalae if Rupture left untreated Thrombus/embolus development Death Treatments Surgery Red flag? Refer? Refer to surgeon/ hospital Category (Primary System) Cardiovascular Condition Name Hypotension Definition/ Risk Factors Decreased BP → Systolic < 90mmHg, Diastolic 20mmHg systolic or >10mmHg diastolic on standing after lying down for at least 2 mins 2. Sudden: assess for injury (internal bleeding) 3. Secondary: d/t drugs, heart pathology, anemia, meditation, hormones, blood flow obstruction 4 Symptoms Light-headedness Dizziness Fainting Seizures Investigations Lab test or PE Positive Sign Sphygmomanometer BP reading 140/90mmHg *high salt diet, low Mg/Ca, smoking, alcohol, insulin resistance, obesity, M>F, African descent, age >30yrs, FHx Notes Increased cardiac output and peripheral resistance leading to elevated pressure in the vessels Classifications: 1. Primary: unknown etiology 2. Secondary: d/t underlying causes such as ABCDE Apnea, Aldosteronism Bruits, Bad kidneys Coarctation, Cushing’s, Catecholamines, Calcemia Drugs Endocrine disease: hyperthyroidism, hyperparathyroidism, pheochromocytoma, hypercalcemia Drug causes Alcohol Decongestants MAOIs Amphetamines Estrogens/OCP NSAIDs Cocaine Lithium Steroids Symptoms Asymptomatic = BENIGN HYPERTENSION Headaches Flushed facies Vertigo Epistaxis Tinnitus Anxiety Altered Vision + Sx/S of secondary disorder Investigations Lab test or PE Positive Sign 5  Physical exam Dependent on secondary disorder Sphygmomanometer Elevated BP >140/90mmHg (sys/dia) After rest for 2 mins Test 3 consecutive days to confirm Measuring both arms Ophthalmoscope AV nicking, cotton wool spots Blood Electrolytes, CRP, Creatine, fasting glucose/ HbA1c, lipid panel ECG Assess heart function (preventative) Urinalysis Assess organ function (preventative) Progressions/Sequalae if Retinopathy left untreated CAD, CHF, renal failure, peripheral vascular disease, Stroke Treatments Ideal BP 120mmHg diastolic *MI, acute renal failure, high stress, eclampsia, pheochromocytoma, drugs Notes Associated with end organ damage (CNS, renal, pregnancy, etc.) Symptoms CNS Vision Renal Cardiac GI Stroke, Vision changes Proteinuria Chest pain N/V Headache, Retinal RBC casts Back pain Abd pain Seizures hemorrhage ↑BUN CHF ↑Liver Hemorrhage Exudates ↑Creatinine Ischemia enzymes Cog changes papilledema - Investigations Lab test or PE Positive Sign Opthalmoscope Exudates, cotton wool spots, papilledema (optic disc edema) BP Elevated BP >180/120mmHg (sys/dia) Blood CBC, electrolytes, creatinine, eGFR Urinalysis BUN, creatinine elevated CXR Heart and lung function if SOB ECG If chest pain to assess heart function Head CT If neurological symptoms Progressions/Sequalae if Death, organ damage left untreated Treatments Must lower BP within 24-48hr Can lower BP by 20-25% by initiating anti-HTN therapies immediately Red flag? Refer? IMMEDIATE HOSPITALIZATION 6 Category (Primary Cardiovascular System) Condition Name Ischemic Heart Disease (IHD) Definition/ Risk Factors Ischemia resulting from atherosclerosis of coronary arteries resulting in myocardial damage, scarring or death. *M>F, age 50-70yrs *vasculitis, embolism, anemia, hypoxemia, congenital, myocardial hypertrophy, aortic stenosis, Notes 3 syndromes: 1. Angina Pectoris: intermittent chest pain 20mins, not relieved by nitroglycerine) 3. Chronic ischemic heart disease: heart failure d/t ischemia Symptoms Substernal chest pain, tightness and discomfort radiating to the left Orthopnea (SOB that occurs when lying flat) Paroxysmal nocturnal dyspnea Tachycardia Cardiomegaly Investigations Lab test or PE Positive Sign Auscultations Arrythmias can be heard ECG & ECG stress test Arrythmia, prolonged PR, ST depression, inverted T wave Echocardiography Visualising arrythmias Coronary angiography Confirming occlusions Intravascular U/S Confirming occlusions/ischemia MRI Confirming occlusions/ischemia Lipid Panel Progressions/Sequalae if MI left untreated Heart Failure Sudden Cardiac death (often caused by CAD) Treatments Nitroglycerine Vasodilation Vascular tonics Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Myocardial Infarction (Heart Attack) Definition/ Risk Factors Restriction of Blood supply → Necrosis of myocardial tissue causing tissue death *M>F, atherosclerosis, exercise exacerbates Notes Symptoms Sudden onset Dull Pain radiation towards jaw and left arm 7  Diaphoresis (unusual sweating) Will last longer than 20mins Not relieved by nitroglycerine N/V Fatigue Dyspnea Investigations Lab test or PE Positive Sign Blood -Elevated Creatine Kinase-MB (peaks in the first day) -Elevated Troponin 1 within 2-4hrs (remain elevated for 2 weeks) -elevated AST (6-36hrs post MI) ECG LARGE Q waves (widened) ST-segment elevation T-wave inversion Ddx. Pericarditis, esophageal disorders, mitral valve prolapse, aortic stenosis, pneumothorax, aortic aneurysm, endocarditis, peptic ulcer disease, pulmonary embolism Progressions/Sequalae if CHF, cardiogenic shock, cardiac arrest, death left untreated Treatments REST and DESTRESS Reduce cardiac workload O2 therapy, ASA, nitroglycerine (improve hypoxemia and ischemia) Anticoagulants ACEi and B-blockers Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Cardiac Arrest Definition/ Risk Factors Heart stops functioning/ pumping blood through the body (abruptly) *cardiac arrythmias, CAD, IHD, non-ischemic heart dz, PE, internal bleeding, Trauma, drug overdose Notes 400,000 people/yr in US → 90% mortality rate Can be temporary Symptoms Abrupt onset Preceded by brief seizures < 5 secs Unconscious/ collapse Non-breathing/ rapid shallow breaths Decreased mental alertness Investigations Lab test or PE Positive Sign Auscultation NO heartbeat Sphygmomanometer Hypotension Peripheral pulses Diagnosed by no pulse (carotid m/c) Progressions/Sequalae if Death left untreated Treatments CPR Red flag? Refer? EMERGENT – CPR should be rapidly started 8 Category (Primary System) Cardiovascular Condition Name Transient Ischemic Attack Definition/ Risk Factors Focal neurological problem d/t short-duration ischemia in the brain *atherosclerosis, CHD (coronary heart disease), Atrial-fib, HTN, DM, polycythemia, smoking Notes Result of vascular occlusion secondary to thromboembolic dz causing cell hypoxia Symptoms Lasting 2min – 2hours Carotid artery Unilateral/ipsilateral blindness Contralateral hemiparesis w/paresthesia Aphasia Dysarthria (difficulty speaking because the muscles you use for speech are weak) Vertebrobasilar deficits Confusion Vertigo Bilateral blindness Diplopia Bilateral or unilateral weakness Limb paresthesia dysarthria Investigations Lab test or PE Positive Sign Carotid artery duplex scan Confirming blood flow Neuroimaging Assessing blood flow/ perfusion Ddx. Seizure, meniere’s disease, hypoglycemia Progressions/Sequalae if Stroke, trauma, seizure left untreated Treatments Supplemental O2 ASA (to improve blood flow) Red flag? Refer? Refer if TIA lasts >2mins Category (Primary System) Cardiovascular Condition Name Cerebrovascular Accident (Ischemic Stroke) Definition/ Risk Factors Ischemia to portion of the brain → loss of function and cell death *> 55yo, smoker, HTN, polycythemia, sickle cell anemia, prior stroke/TIA, A-fib, acute MI Notes Symptoms Sudden onset, usually unilateral Altered consciousness act FAST Facial droop (paralysis) Arms (hemiparesis, hemisensory deficits) Slurred Speech (aphasia) Time (call 911 immediately → >20mins = permanent brain damage) Investigations Lab test or PE Positive Sign CT scan Acute stroke/ visualize ischemia MRI Structural details to visualize edema 9  Ddx. Focal seizure, tumor, aneurysm, epidural hematoma (sudden onset: after head trauma) Subdural hematoma (slow onset, weeks after trauma) Progressions/Sequalae if UMN dysfunction left untreated Sympathetic dystrophies Semi-permanent hemiparesis Treatments Supplemental O2 Thrombolytic therapy (within 3hrs) Antiplatelet treatments (ASA, clopidogrel) Warfarin for embolic type strokes Treat risk factors Red flag? Refer? EMERGENT – send to ER Category (Primary System) Cardiovascular Condition Name Avascular necrosis (of the femoral head) Definition/ Risk Factors Interruption of blood supply to the femoral head bone *young adults ~38yrs Notes Commonly d/t femoral head fracture, Legg-calve-Perthes, RA, SLE Symptoms Painless at first Pain < with weight bearing exercise, > rest Pain on internal rotation Investigations Lab test or PE Positive Sign Passive RoM Reduced and painful Internal rotation Pain X-ray Revealing OA or bone fracture MRI *more sensitive and specific* can reveal blood perfusion Ddx. OA, osteophytes, Hip pathology, peripheral vascular dz Progressions/Sequalae if Osteoarthritis left untreated Treatments Surgery NSAIDs for pain Red flag? Refer? Refer for surgical consult Category (Primary System) Cardiovascular Condition Name Gangrene Definition/ Risk Factors Necrosis of tissue due to ischemia *peripheral vascular dz, DM, infection, thrombosis, smoking Notes Infection = C. perfingens Classifcations: Wet Abrupt, occurs in moist tissue/organs (mouth, lungs, etc.) D/t vein or arterial obstruction – injury, frostbite, burns, etc. Infection can develop 🡪 sepsis Dry Intense pain Associated with DM, not infectious (NO SEPSIS) Gas Gangrene 10  Bacterial endotoxins 🡪 gas production, myonecrosis and sepsis Severe pain Necrotising fasciitis Flesh eating disease Infection of deeper skin and subcutaneous layers Bacterial toxins 🡪 Kill muscle cells and skin Symptoms Pain Numbness Dry, scaly skin Poor hair and nail growth Ulcerations/atrophy of the leg Investigations Lab test or PE Positive Sign Visual Skin drying, poor hair and nail growth, muscle atrophy WET Moist organs, coagulative necrosis 🡪 liquefactive necrosis DRY dry, shiny, hyperpigmented with flaking skin GAS Pale 🡪 red w bullae 🡪 black-green wound Severe edema Bad smell NECROTIZING FASCIITIS Rapid onset, blackened skin Ddx. Abscess, cellulites, toxic exposure Progressions/Sequalae if Life threatening left untreated Tissue and function loss Amputation Septic shock & Toxemia Wet Grangrene = poor prognosis Treatments Antibiotics Surgery Proper wound care Red flag? Refer? EMERGENT – surgical consult Arrythmias Category (Primary System) Cardiovascular Condition Name Atrial Fibrillation Definition/ Risk Factors Loss of regular atrial contractile rhythm out of sync with ventricular contraction *HTN, AV valve disorder, Hyperthyroidism, cardiomyopathy *M>F, white, elderly, previous heart pathology, FHx Notes MOST COMMON CARDIAC ARRYTHMIA Acute/ Flutter (F, elderly, hypoxia, alcohol, smoking, cardiomyopathy Notes Not pathological, commonly found in healthy hearts Symptoms Asymptomatic Possible palpitations SOB 12  Dizziness Investigations Lab test or PE Positive Sign ECG QRS width >120ms, abnormal shape DIAGNOSTIC Holter monitor Monitoring heart rhythm, noting arrythmias Progressions/Sequalae if V-tachycardia left untreated Treatments No treatment if asymptomatic b-blockers, CCB if symptomatic Electrolyte replacement/ Magnesium, Potassium Lifestyle modifications Category (Primary System) Cardiovascular Condition Name Heart Block Definition/ Risk Factors A problem affecting the electrical impulses of the heart *elderly Notes Classifications: First Degree - Delay in conduction b/w SA node and ventricles - Ventricles do not receive every signal sent - *increase vagal tone, B-blockers, CCB use Second Degree (Mobitz 1 = Wenckebach’s) - PR interval gets progressively more extended - Delayed electrical signal 🡪 heart skips a beat - Drug effects or increased vagal tone Second Degree (Mobitz 2) - More serious than Mobitz 1 - Less regular pattern of heartbeat skips - QRS not following each P wave, PR internal stays constant Third Degree - No electrical signals reach the ventricles - QRS showing up sporadically and not in sync with P wave at ALL Symptoms 1st = increased vagal tone, but asymptomatic 2nd= Asymptomatic or Syncope 3rd degree Syncope Dizziness Acute HA Hypotension Fainting Investigations Lab test or PE Positive Sign ECG/ EKG See above clasifications for results 13 Progressions/Sequalae if Anterior wall MI left untreated Arrhythmias Asystole Treatments Pacemaker Removal of any medications responsible Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Sinus Bradycardia Definition/ Risk Factors Heartbeat 100BPM ECG/EKG Regular rhythm Holter monitor Assess for 72hrs Progressions/Sequalae if Ischemic heart disease (decreased filling), valvular disease left untreated Treatments No treatment if physiological B-blocker/CCB if symptomatic Red flag? Refer? 14 Category (Primary System) Cardiovascular Condition Name Supraventricular Tachyarrhythmia (SVT) Definition/ Risk Factors Sudden burst of elevated heart rate that originates from the AV node or within atria *alcohol, tobacco, caffeine, anxiety, SA/AV ischemia, meds (digoxin), COPD, pneumonia, Wolff-Parkinson White Syndrome Notes Very common in healthy people Symptoms Palpitations Presyncope/ syncope Dizziness SOB Chest discomfort Investigations Lab test or PE Positive Sign Pulse Pounding, >100bpm ECG Narrow QRS complex Ddx. Sinus/ ventricular tachycardia Progressions/Sequalae if Heart disease left untreated Cardiomyopathy CHF Hypotension Treatments Vagal stimulation (e.g., Valsalva, carotid massage) to block AV conduction Adenosine IV push (6mg-12mg) Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Ventricular Tachycardia Definition/ Risk Factors 3 or more consecutive ventricular beats >100bpm *MI, cardiomyopathy, valvular disease, myocarditis, hypoxemia Notes Considered Sustained V-tach if lasting >30sec – medical emergency Symptoms Palpitations Fainting Chest discomfort Dizziness SOB Investigations Lab test or PE Positive Sign Pulse >100, on average >140-200bpm ECG Wide regular QRS (140ms), abnormal P-wave Progressions/Sequalae if V-fib left untreated MI Sudden cardiac death Treatments If Sustained = immediate treatment- CPR + defibrillator Antiarrhythmic drugs 15 Red flag? Refer? Refer to ER if Sustained >30 sec Category (Primary System) Cardiovascular Condition Name Ventricular Fibrillation (V-fib) Definition/ Risk Factors Loss of regular heartbeat, causing ventricular quivering and inefficient pumping *CAD, stress, M>F, ischemic heart disease, cardiomyopathy, myocarditis, acidosis Notes Symptoms Palpitations Fatigue Weakness Syncope/Collapse Hypotension Chest Discomfort Investigations Lab test or PE Positive Sign ECG Erratic readings, no identifiable waves Progressions/Sequalae if MI left untreated Sudden cardiac death Treatments CPR + Defibrillator Red flag? Refer? MEDICAL EMERGENCY – call EMS Degenerative Category (Primary System) Cardiovascular Condition Name Dilated Cardiomyopathy Definition/ Risk Factors Non-inflammatory enlargement of the heart muscles. Four-chamber hypertrophy, unexplained dilation, and impaired systolic function *alcoholism, thiamine deficiency, genetics, myocarditis, drugs, peripartum (within 6 months postpartum) Notes Idiopathic disease Symptoms SOB Weakness Palpitations? Investigations Lab test or PE Positive Sign CXR/ Doppler U/S Enlargement of heart w/ all 4 chambers dilated B-type Natriuretic peptide (BNP) Monitors severity of fluid overload Auscultation Murmurs (regurgitation), S3 & S4 heart sounds, arrythmias Blood CBC, electrolytes, elevated CK, CK-MB, troponin 16  ECG Nonspecific S-T wave changes Q waves Pulse Narrow pulse pressure Angiography r/o ischemic heart disease Progressions/Sequalae if Sudden Death left untreated Treatments Treat underlying disease ACEi, ARBs, B-blockers, Cardiac glycosides, vasodilators, Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Hypertrophic Cardiomyopathy Definition/ Risk Factors Non-inflammatory enlargement of the heart muscles. Hypertrophy of the ventricles, mainly the IV septum. *autosomal dominant Chromosome 14. Notes Symptoms Palpitations Dizziness (esp. with rapid movement) Stable Angina SOB on exertion Investigations Lab test or PE Positive Sign Auscultation Split S2, S4 present, crescendo-decrescendo systolic murmur Cardiac apex impulse Palpable cardiac apical impulse ECG Abnormal and prominent Q-wave, short P-R interval Echocardiograph DIAGNOSTIC OF HYPERTROPHY Progressions/Sequalae if Obstruction of the blood flow below the aortic valve left untreated Left ventricular outflow obstruction Treatments Avoid strenuous exercise B-blockers Amiodarone – for ventricular arrythmia Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Restrictive Cardiomyopathy Definition/ Risk Factors Non-inflammatory enlargement of the heart muscles. Impaired ventricular filling or decreased ventricular compliance with normal systolic function (stiffened heart) – tin heart *amyloidosis, sarcoidosis, myocardial fibrosis, surgery, radiation Notes Symptoms Gradually worsening SOB 17  Exercise intolerance Fatigue Investigations Lab test or PE Positive Sign JVD Elevated, distended jugular vein Auscultation S2 split heart sounds, S3 may be present (early diastolic filling), murmurs ECG May have non-specific ST-T wave changes, low QRS voltage CXR Mild cardiac enlargement Ventricular biopsy CONFIRM ETIOLOGY Progressions/Sequalae if CHF with normal left ventricular systolic function left untreated Treatments Treat underlying cause Diuretics Vasodilators ACEi Anticoagulants Red flag? Refer? May require heart transplant Category (Primary System) Cardiovascular Condition Name Congestive Heart Failure Definition/ Risk Factors Inability of the heart to pump enough blood to meet O2 demands of peripheral tissue *CAD, HTN, cardiomyopathy, DM, atherosclerosis, stenosis, viral myocarditis, cor pulmonale *smokers, alcoholics Notes Left Sided: causes SNS activation, renin-aldosterone activation Right Sided (m/c due to left sided heart failure) New York Heart Association (NYHA) Classifications Class 1: no symptoms of heart failure at rest or during PA Class 2: no symptoms at rest, present with ordinary PA Class 3: symptoms present at less than ordinary PA Class 4: PA at any level elicits symptoms Symptoms Dyspnea Left CHF Fatigue Syncope Systemic hypotension Pulmonary HTN Tachycardia (due to SNS compensation of low cardiac output) Cool extremities and peripheral cyanosis Cough Paroxysmal nocturnal dyspnea (PND) Right CHF Left sided symptoms + Portal hypertension 18  Peripheral edema Investigations Lab test or PE Positive Sign Blood Elevated ANP, creatinine, electrolytes, elevated BUN, HbA1c, albumin, LFTs, lipid profile Cap refill >2sec refill Lungs Crackles and Rales Heart Auscultation Mitral regurgitation murmur, S3 sounds JVD Elevated jugular vein (RIGHT SIDED) Abd exam Hepatomegaly (RIGHT SIDED) ECG and Echo Investigations of heart quality Progressions/Sequalae if Angina & MI left untreated Ischemic bowel infarction Reduced kidney function Malabsorption Arrythmias - Ventricular fibrillation Pulmonary edema Treatments EMERGENCY Vasodilators (ACEi, Angiotensin II receptor blockers) B-blockers 🡪 introduce slowly, may increase heart failure Diuretics Inotropes (Digoxin) Antiarrhythmic drugs (Amiodarone) Anticoagulants (Warfarin) Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Aortic Stenosis Definition/ Risk Factors Constriction of the valve with reduced function and obstruction of blood flow *elderly, Rheumatic fever, congenital bicuspid aortic valve (rather than tricuspid), arteriosclerosis + calcification Notes Leads to increased end-diastolic pressure Heart muscles go through left ventricular hypertrophy Symptoms Syncope + angina+ Dyspnea on exertion Paroxysmal nocturnal dyspnea Orthopnea Peripheral edema Investigations Lab test or PE Positive Sign Peripheral pulses Reduced and delayed compared to LV contraction PMI (point of maximal impulse) Palpable and sustained Heart auscultation Crescendo-decrescendo ejection murmur radiating to R. clavicle and both carotid arteries, S3 and S4 present ECG LV hypertrophy, LA enlargement 19  Echo Reduced valve area, LV hypertrophy, reduced LV function Ddx. Carotid bruits, physiological murmur, mitral regurgitation, rheumatic disease Progressions/Sequalae if CHF left untreated Arrhythmia Angina Death Hemolytic anemia Treatments Asymptomatic = rest and no overexertion Symptomatic = can use B-blockers Red flag? Refer? If surgery is required Category (Primary System) Cardiovascular Condition Name Mitral valve stenosis Definition/ Risk Factors Narrowing of mitral valve, reducing function, and preventing blood flow to left ventricle *Rheumatic heart disease, F>M Notes d/t thickening and hardening of mitral valve leaflets/ chordinae Symptoms A-fib Stable angina Paroxysmal nocturnal dyspnea Dypsnea on exertion Fatigue Pulmonary edema Hemoptysis Malar slush, pinched and blue facies (esp. w/ severe MS) Investigations Lab test or PE Positive Sign Echo and ECG Hypertrophy of left atrium, restricted opening of mitral valve Heart Auscultation Mid-diastolic rumble (apex) Loud opening snap after S2 Loud S1 and S2 heard on EXPIRATION CXR LA enlargement, mitral valve calcification Ddx. Atrial myoma (rare) Progressions/Sequalae if Thromboembolism left untreated Bacterial endocarditis PE Pulmonary edema Recurrent Rheumatic fever Right sided CHF (d/t pulmonary HTN) Treatments Diuretics B-blockers CCB’s Anticoagulants 20  Valve replacement Red flag? Refer? If surgery is required Category (Primary System) Cardiovascular Condition Name Pulmonary Stenosis Definition/ Risk Factors Decreased function and constriction of the pulmonic heart valve from the right ventricle *endocarditis, pulmonary HTN, intrauterine rubella, rheumatic disease Notes M/C congenital etiology Symptoms Chest pain/discomfort Fatigue Syncope Peripheral edema Investigations Lab test or PE Positive Sign Heart Auscultation Mid-systolic crescendo-decresendo murmur (esp. on INSPIRATION or valsalva), right-sided S4, pulmonary ejection click ECG and Echo NEEDED FOR DIAGNOSIS, RV hypertrophy CXR Significant pulmonary arteries, enlarged RV Ddx. Other stenosis, tetralogy of Fallot Progressions/Sequalae if Post-op pulmonic regurgitation, atrial arrhythmia, right sided CHF left untreated Treatments Balloon valvuloplasty if SEVERE Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Tricuspid Stenosis Definition/ Risk Factors Reduced function of tricuspid valve from RA to RV *rheumatic heart disease, congenital, mitral valve stenosis Notes Typically benign Symptoms Pulmonary congestion Dyspnea Fatigue Edema Discomfort in neck- jugular pulsations RUQ abd discomfort Investigations Lab test or PE Positive Sign Abd exam Hepatomegaly, ascites, RUQ tenderness JVD Enlarged jugular vein Heart Auscultation Diastolic rumble at 4th L intercostal, murmur louder on INSPIRATION ECG and Echo Reduced Q, RA hypertrophy NEEDED FOR DIAGNOSIS CXR Enlarged RA, no effect on pulmonary artery Ddx. Tricuspid regurgitation/ insufficiency 21 Progressions/Sequalae if Mitral stenosis left untreated Treatments Diuretics Low-salt diet ACEi Red flag? Refer? If surgery is required Category (Primary System) Cardiovascular Condition Name Aortic Insufficiency (regurgitation) Definition/ Risk Factors Incompetency of aortic valve to close during diastole 🡪 backflow *idiopathic degeneration, RF, infective endocarditis, VS defect, Marfan’s, SLE, trauma Notes Regurgitated blood flows back into the LV🡪 increased preload/ volume overload 🡪 increased pressure, LV dilation and hypertrophy Symptoms Dyspnea (on exertion) HTN Paroxysmal nocturnal dyspnea Orthopnea Angina Syncope Investigations Lab test or PE Positive Sign Pulse Bounding, widened pulse pressure ECG + Echo Hypertrophy of LV, leaflet abnormalities Heart auscultation Early decrescendo, diastolic mumur, late S3, accentuated when LEANING FORWARD and EXPIRATION Ddx. Pulmonic regurg, mitral stenosis, atrial myxoma Progressions/Sequalae if Left ventricular failure left untreated Left CHF Treatments Surgical valve replacement ACEi (vasodilation) CCBs Digoxin Low sodium diet Avoid strenuous activity Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Mitral Insufficiency (Regurgitation) Definition/ Risk Factors Loose closure of the mitral valve allowing backflow into the LA *endocarditis, rheumatic heart dz, CAD, posterior-inferior MI, Marfans, Ehlers-Danlos Notes M/C valvular disease, commonly d/t mitral valve prolapse Less blood in LV 🡪 less cardiac output, increase peripheral pressure Symptoms Dyspnea/ PND Orthopnea Fatigue Palpitations 22  Acute pulmonary edema Hemoptysis with pink tinged sputum Investigations Lab test or PE Positive Sign Heart auscultation Holosystolyic murmur at apex, loud S2, S3 Echo + ECG, CXR LA enlargement, LV hypertrophy NEEDED FOR DIAGNOSIS Ddx. Hypertrophic cardiomyopathy, VSD Progressions/Sequalae if A-fib/ other arrythmias left untreated PE Systemic embolism Left CHF Treatments Diuretics (decrease preload) ACEi to decrease afterload for severe MR Surgery (valve repair/ replacement) Red flag? Refer? If surgery is required Category (Primary System) Cardiovascular Condition Name Tricuspid Insufficiency (regurgitation) Definition/ Risk Factors Incompetence of the tricuspid valve leading to loose closure and backflow into the RA during systole *pulmonary HTN, left sided heart dz, infective endocarditis, RF, congenital (Ebstein anomaly) Notes Leads to further dilatation of the RV Symptoms Usually asymptomatic Fatigue Neck pulsations Palpitations Peripheral Edema Investigations Lab test or PE Positive Sign Heart Auscultations Low-pitched murmur, holosystolic accentuated on INSPIRATION ECG/CXR RA enlargement, RV hypertrophy Echo NEEDED FOR DIAGNOSIS Ddx. Tricuspid stenosis Progressions/Sequalae if Right CHF left untreated Arrythmia/ A-fib Treatments Diuretics to reduce preload Red flag? Refer? If surgery is required Category (Primary System) Cardiovascular Condition Name Pulmonary insufficiency (regurgitation) Definition/ Risk Factors Pulmonic valve does not close properly during diastole leading to backflow into the RV from pulmonary artery 23  *pulmonary HTN, RF, infective endocarditis, tetralogy of Fallot Notes Can occur due to surgical repair of arteries in Tetralogy of Fallot. Increased blood flow into the RV leads to hypertrophy Symptoms Chest pain Syncope Fatigue Peripheral edema Investigations Lab test or PE Positive Sign Heart auscultation Decrescendo diastolic murmur at lower left sternal border, accentuated by INSPIRATION or VALSALVA ECG/CXR Hypertrophy of RV, prominent pulmonary arteries Echo NEEDED FOR DIAGNOSIS Progressions/Sequalae if Right sided CHF left untreated Treatments Treatment not commonly needed May require valve replacement Red flag? Refer? If surgery is required Category (Primary System) Cardiovascular Condition Name Mitral valve prolapse Definition/ Risk Factors Movement of thickend valve leaflets backwards into the LA during systole *young women, Graves dz, Duchenne’s, Sickle cell, ASD, Marfan’s, Rheumatic dz, carnitine def, Mg def Notes Ballooning valve/ billowing mitral leaflets from LV to LA Symptoms Often asymptomatic RARE cases: Chest pain (“stabbing”) Dyspnea Palpitations Fatigue Anxiety/ Panic Investigations Lab test or PE Positive Sign Auscultation Mid-systolic click, accentuated by VALSALVA or squat-to-stand ECG Non-specific ST-T wave change Echo Visualize mitral leaflets in the LA Ddx. Acute panic attacks, anxiety, MV pathologies Progressions/Sequalae if Mitral valve regurgitation left untreated Endocarditis Valve rupture Thromboembolism Sudden death 24 Treatments Asymptomatic = no treatment B-blockers to manage palpitations May require valve replacement Red flag? Refer? If surgery is required Inflammatory/ Infectious Category (Primary System) Cardiovascular Condition Name Polyarteritis Nodosa Definition/ Risk Factors medium vessel vasculitis *age 40-60yrs, M>F, Hepatitis B Notes - Involves any organ EXCEPT the lungs - MAIN ORGANS: renal, coronary, and mesenteric arteries - Fibrinous necrosis develops in tissue, leading to vessel occlusion and ischemia Symptoms Weight loss >4kg Myalgias/weakness Neuropathy Testicular pain/ tenderness Diarrhea (bloody) Investigations Lab test or PE Positive Sign Blood pressure Diastolic< 90mmHg Urinalysis Elevated BUN and Creatinine Angiography or biopsy Confirm lesions Progressions/Sequalae if Thrombosis or aneurysm may occur at any lesion, renal failure, MI, ischemic ulcers left untreated Fatal if left untreated Treatments Corticosteroids Category (Primary System) Cardiovascular Condition Name Temporal arteritis (Giant cell arteritis) Definition/ Risk Factors Large vessel arteritis of the temporal artery *elderly > 50yrs, F>M, NE European, Polymyalgia rheumatica Notes Inflammation leading to thickening intimal layer, narrowing of lumen 🡪 vessel occlusion Symptoms Headache (throbbing, temporal or occipital) Vision changes (monoclonal vision loss, diplopia, blurred vision, ptosis) Jaw claudication (muscle fatigue of jaw muscles) Masseter & temporalis muscle pain Investigations Lab test or PE Positive Sign Blood ESR>100, elevated CRP Ophthalmoscope Optic artery atrophy Palpation Scalp tenderness Biopsy of temporal artery confirmatory = gold standard 25 Progressions/Sequalae if Irreversible blindness left untreated Treatments Corticosteroids Red flag? Refer? EMERGENT – start treatment even before confirmation if suspected Category (Primary Cardiovascular System) Condition Name Polyangiitis with Granulomatosis (Wegner’s Disease) Definition/ Risk Factors Small vessel vasculitis affecting the nasal, pulmonary and renal arteries *M=F, age 40-65yrs Notes C-ANCA antibody Symptoms Hemoptysis Bilateral lung nodes Hematuria Glomerular nephritis Investigations Lab test or PE Positive Sign Blood C-ANCA antibody present Tissue biopsy confirmatory Ddx. Microscopic polyangiitis, HSP, Churg-Strauss dz Progressions/Sequalae if Kidney Failure left untreated Treatments Cyclophosphamide + Corticosteroids Red flag? Refer? -- Category (Primary System) Cardiovascular Condition Name Rheumatic Fever + Heart Disease Definition/ Risk Factors Acute inflammation complication from Group A strep infection d/t immunological cross reactions damaging the heart *Type A beta-strep, malnutrition, pharyngitis, children ~10yrs, F>M but < 3% chance Notes Strep pyrogens infection, incubation of 2-4 days Symptoms JONES CRITERIA – 2 major, or 1 major and 2 minor symptoms Joint pain – polyarteritis of the large joints - Carditis Nodules Erythema marginatum – annular lesion with red borders Systemic chorea Minor: Fever, chills, arthralgias, elevated CRP, prolonged PR on ECG Investigations Lab test or PE Positive Sign Temp Fever 38.2-38.9C Blood Elevated ESR, CRP, Leukocytosis ECG Prolonged PR interval Oral exam Erythema, signs of pharyngitis Throat culture Group A strep 26  Heart Murmurs on auscultation, Cardiomegaly on CXR Ddx. Autoimmune cardiomyopathy, pericarditis, aortic stenosis Progressions/Sequalae if Rheumatic valvular dz – mitral stenosis, aortic insufficiency left untreated Endocarditis Treatments Penicillin is effective in treating Strep throat infection, and preventing RF Aspirin for joint pain Prednisone for severe carditis Category (Primary Cardiovascular System) Condition Name Thrombophlebitis Definition/ Risk Factors Erythema, hardening and tenderness along the superficial vein, usually spontaneous but can occur after intravenous cannulation *trauma, SLE, varicose veins, polycythemia, thrombocytosis Notes Inflammatory and immune mediated response M/C in greater saphenous vein and below Symptoms Palpable cord/mass within the vein Pain Redness Edema Dilated vein Investigations Lab test or PE Positive Sign Visual Erythema, Edema Peripheral pulses asymmetry Vitals Elevated temp and BP Dopple U/S Exclude associated DVT Arteriography Detecting blockage/narrowing vessel Progressions/Sequalae if DVT, PE left untreated Treatments Moist heat Compression socks, Elevation Ambulation (walking, cycling) Mild analgesic/ anti-inflammatory Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Endocarditis Definition/ Risk Factors Acute infection of the cardiac endothelium by bacteria or fungi *prosthetic heart valve, IV drugs, congenital heart disease, MVP, aortic stenosis, Notes M/c valves involved are left sided 🡪 mitral valve >> aorta >> tricuspid >> pulmonary [ in 50% of IV drug cases, tricuspid also involved] The more virulent the organism (e.g., staph, strep) the more aggressive the disease S. viridans – low virulence (will only infect already damaged cells) S. aureus – high virulence (will infect ANYONE) S. epidermis – prosthetic valves 27  S. bovis – associated with colorectal cancers Symptoms High fever Night sweats Fatigue Weight loss Left-valve insufficiency Tachycardia SOB Pallor Petechiae Splinter nail hemorrhage Janeway lesions: painless rash on palms and soles Osler nodes: painful nodules on the fingers and toes *ouch, ouch osler* Investigations Lab test or PE Positive Sign Auscultation Regurgitation murmurs Abd exam splenomegaly Skin Petechiae on the legs, Janeway lesions on hands/feet, Osler nodes on fingers and toes Blood Normocytic anemia of chronic dz, elevated ESR, RF, leukocytosis (neut) Echo Vegetations, regurgitation, abscess ECG Increased PR interval Ddx. MI, pericarditis, SLE, RF, brain abscess, TB, glomerulonephritis, meningitis, hemolytic anemia Progressions/Sequalae if CHF, MI, pericarditis, arrythmia, emboli, acute renal failure, DEATH left untreated Treatments Antibiotics (IV) for min 4-6weeks Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Myocarditis Definition/ Risk Factors Inflammation of the myocardium causing dilation and hypertrophy of all four chambers + lymphocytic infiltrate *URI, coxsackie, RMSF, Chagas dz, viral infection, acute rheumatic fever, drugs, autoimmune Notes Viral: parvovirus B19, coxsackie B, HIV, poliovirus, influenza, mumps Bacteria: C. diptheria, S. aureus, Rickettsia, borrelia burgdorgeri Protozoa: Chagus (trypanosoma cruzi), toxoplasmosis Symptoms Fever Chest pain Biventricular heart failure Tachycardia & heart palpitations Dyspnea Investigations Lab test or PE Positive Sign Blood Leukocytosis: Neut = bacteria, Mononu= viral, Eosin = Fiedler 28  Elevated CK-MB, Troponin !, LDH, AST, ESR, ANA, RF Auscultation Friction rubs, heart murmurs Jugular vein Elevated JV pressure ECG Arrythmia, St-T changes Echo Cardiomegaly, tachycardia, wall motion abnormalities Endomyocardial biopsy Confirmatory Ddx. Pulmonary HTN, hypothyroid, malignancy, recurrent PE Progressions/Sequalae if Pulmonary emboli left untreated Dilated cardiomyopathy Death (sudden) Treatments Treat underlying cause – e.g antibiotics for bacterial infection Restrict PA Anticoagulation Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Pericarditis Definition/ Risk Factors Inflammation of the pericardial tissue *AI, cancer, endocarditis, trauma, surgery MI, drugs Notes IT RUBSS: infarct, tumor, RF, uremia, bacterial/viral, SLE, scleroderma Viral: Coxsackie B Bacterial: S. aureus, S. pneumonia, TB Fungal: Histoplasmosis, blastomycosis Symptoms Acute chest pain + Friction Rub + ECG changes Fever Radiating pain < cough/ breathing > Leaning forward Dyspnea/ Tachypnea Weakness Investigations Lab test or PE Positive Sign ECG ST elevation, PR depression Blood CK-MB normal, elevated ESR + CRP, elevated Troponin I & T Auscultation Pericardial friction rub, muffled heart sounds Echo Cardiac tamponade CXR Enlarged cardiac silhouette + effusion Ddx. MI, cardiac tamponade, PE, aortic dissection, pancreatitis Progressions/Sequalae if Pericardial tamponade, obstructive pericarditis left untreated Treatments Treat underlying cause Anti-inflammatory agents (NSAIDs/ ASA for 7-14days) Colchicine to reduce recurrent pericarditis Red flag? Refer? Send to ER to drain fluids 29 Autoimmune Category (Primary System) Cardiovascular Condition Name Vasculitis. Definition/ Risk Factors Inflammation of the vascular membranes/ blood vessles Notes Large vessel: Temporal arteritis, Takayasu’s arteritis Medium vessel: Polyarteritis nodosa, Kawasaki’s dz, Buerger’s dz Small vessel: Wegner’s, Microscopic Polyangiitis, Churg-Strauss, HSP Symptoms Non-specific, dependent on the vessels affected Consider patients with systemic illness Purpura Investigations Lab test or PE Positive Sign Pulse asymmetrical Blood Elevated ESR Progressions/Sequalae if Tissue necrosis, thrombosis left untreated Treatments Corticosteroids commonly… Red flag? Refer? Category (Primary System) Cardiovascular Condition Name Necrotizing Vasculitis Definition/ Risk Factors Inflammation of the blood vessels leading to ischemia and necrosis *elderly, polyarteritis nodosa, Small/Medium/Large vasculitis dz, SLE, Notes Type 3 hypersensitivity, possible autoimmune factors Diagnosed by Hx taking and suspicion Symptoms Multi organ ischemia Systemic illness Fever Chills Fatigue Arthritis Weight loss Investigations Lab test or PE Positive Sign Blood ESR, CRP elevated Tissue biopsy Ddx. SLE, malignancy, glomerulonephritis, tissue necrosis Progressions/Sequalae if Organ failure, shock left untreated Treatments Corticosteroids and immune suppressors to slow progression Red flag? Refer? Traumatic Category (Primary Cardiovascular System) 30 Condition Name Hypovolemic Shock Definition/ Risk Factors Decreased blood volume causing shock *blood loss, meds, vasodilation, extreme temperatures, infection Notes d/t internal or external bleeding (hemorrhage), burns, lesions, heavy sweating, diarrhea, vomiting Symptoms Tachycardia Oliguria Lethargy Confusion Investigations Lab test or PE Positive Sign Sphygmomanometer Low BP Peripheral Pulse weak/absent peripheral pulses Touch Pale and cool/clammy extremeties Auscultation Tachycardia Progressions/Sequalae if Multi-organ failure left untreated Treatments IV fluids Oxygen therapy First aid 🡪 depending on concern Red flag? Refer? Chest Injuries with CV implications - Rib Fracture - Pneumothorax - Internal Bleeding - Puncture wounds 31