Cardiology

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desaix
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195117
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Cardiology
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2014-04-07 16:17:03
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Cardiology
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  1. Approach to EKGs
    • 1 Rate (Tachy >100, brady <60)
    • 2 Rhythm (Regular, Irregular)
    • 3 Axis (LAD or RAD - Normal = -30 to 90)
    • 4 Intervals (PR < 200ms, QRS < 120, QT <460)
    • 5 Chamber Abnormality (LAA, RAA, LVH, RVH)
    • 6 QRST changes (Q waves, poor R-wave progression V1-V6, ST, T-wave changes)
  2. Heart Vessels
    RV -> RCA right coronary artery - travels posteriorly between AV groove and at crux of heart -> PDA post descending artery travels to posterior

    • LV -> LAD left anterior descending - anterior and anteriolateral LV;
    • -> LCx left circumflex coronary artery -> left AV groove -> LA & posterolateral LV
  3. Heart Innervation
    SA -> AV -> Bundle of His -> RBB

    LBB -> Anterior fascicle and posterior fascicle
  4. JVP waveform
    • A wave = right Atrial contraction and ends synchronously with the carotid artery pulse. C wave = right ventricular Contraction causing the triCuspid valve to bulge towards the right atrium
    • X descent = relaXation and rapid atrial filling due to low pressure.The " x' " (x prime) descent follows the 'c' wave and occurs as a result of the right ventricle pulling the tricuspid valve downward during ventricular systole. The x' (x prime) descent can be used as a measure of right ventricle contractility
    • V wave = Venous filling when the tricuspid valve is closed and venous pressure increases from venous return - this occurs during and following the carotid pulse.
    • Y descent = rapid emptYing of the atrium into the ventricle following the opening of the tricuspid valve.
  5. NYHA Functional Classification
    I Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.

    II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.

    III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m).Comfortable only at rest.

    IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
  6. CHADS2 Score
    • A fib management
    • C - CHF (past or present)
    • H - HTN (treated or not)
    • A - Age >75
    • D - DM
    • S2 - Prior stroke, TIA, Thromboembolism

    • Annual Stroke Risk:
    • 0 = 1.9 (Low risk) - None or ASA
    • 1 = 2.8 (mod risk) - ASA or warfarin
    • 2 = 4.0 (high risk) - warfarin
    • 3 = 5.9
    • 4 = 8.5
    • 5 = 12.5
    • 6 = 18.2
  7. Causes of high amplitude pulse
    • 1. Aortic insufficiency
    • 2. Anemia
    • 3. Pregnancy
    • 4. Thyrotoxicosis
  8. Decreasing pulse amplitude
    • 1. Hypovolemia
    • 2. Tachycardia
    • 3. LV failure
    • 4. Severe Mitral stenosis
  9. Pulses:
    1. Aortic insufficiency
    2. Aortic stenosis
    3. Aortic regurgitation/Hypertrophic CM
    4. Severe LV Dysfunction/Afib
    5. Tamponade/COPD/pericarditis/hypovolemic shock/pregancy
    • 1. bounding pulse - Corrigan or water-hammer
    • 2. pulsus parvus et tardus (attenuated up stroke and late)
    • 3. bisferious pulse - two systolic peaks
    • 4. pulsus alternans - alternating intensity from beat to beat
    • 5. pulsus paradoxus - >10 mm Hg decrease in SBP with inspiration
  10. Leriche's syndrome
    • 1. claudication of buttocks and thighs
    • 2. absent/decreased femoral pulses
    • 3. impotence
  11. Levine Scale
    • 1. Murmur heard with difficulty
    • 2. Faint murmur but immediately heard with stethoscope
    • 3. Loud murmur, no thrill
    • 4. Loud murmur with thrill
    • 5. Loud murmur with thrill - audible with just rim of stethoscope
    • 6. Loud murmur with thrill - audible to stethoscope above chest
  12. Intensity of S1
    • Loud: Short PR (short filling time)
    • Mitral stenosis w pliable valve
    • Soft: Long PR 
    • Mitral regurgitation
    • Poor LV function
    • Thick chest wall
    • Mitral stenosis with rigid valve
    • Varying: Afib
    • Heart block
  13. Intensity of A2
    • Loud: Systemic hypertension
    • Aortic dilation
    • Coarctation 
    • Soft: Calcific aortic stenosis
    • Aortic regurgitation
  14. Intensity of P2
    • Loud:Pulmonary HTN
    • Thin chest wall
    • Soft: pulmonic stenosis
  15. Single S2
    • 1 Pulmonic stenosis
    • 2 Systemic HTN
    • 3 CAD
    • 4 Paradoxical splitting S2 conditions
  16. Paradoxically Split S2
    • 1 LBBB
    • 2 RV pacing
    • 3 Angina, MI
    • 4 Aortic stenosis
    • 5 HCM
    • 6 Aortic Regurg
  17. Wide S2 (with normal respiratory variation)
    • 1 RBBB
    • 2 LV pacing
    • 3 Pulmonic stenosis
    • 4 PE
    • 5 Idiopathic dilation of pulmon artery
    • 6 Mitral Regurg
    • 7 VSD
  18. Fixed Split S2
    • 1 ASD
    • 2 Severe RV dysfunction
  19. S3 (ventricular diastolic gallop)
    • - best heard cardiac apex, left lateral dec
    • - pathologic if old age or cardiac disease
    • - increased with maneuvers that accentuate venous return
  20. S4 (atrial diastolic gallop)
    • - best heard at apex with bell
    • - blood ejected into non-compliant ventricle
    • - not present in a fib
    • - lvh, acute mi
  21. Opening Snap
    opening of abnormal mitral or tricuspid valves with rheumatic valvular stenosis

    -sound caused by leaflet doming in early systole
  22. Systolic Murmurs
    1. Ejection Murmurs (cres-decr)
    2. Regurgitant (holosystolic)
    3. Early diastolic (decrescendo)
    4. Mid diastolic/diastolic rumble
    • 1. innocent, A sclerosis, Aortic stenosis, pulmonic stenosis, hcm (louder w/ dec VR, no radiation)
    • 2. MR, TR, sometimes VSD
    • 3. aortic/pulmonic insufficiency (regurgitation)
    • 4. mitral/tricuspid stenosis
  23. Pericarditis
    (1) pleuritic chest pain; (2) friction rub; and (3) diffuse concordant ST-segment elevation on electrocardiography, often with depression of the PR segment.
  24. Aortic dissection
    • Severe onset pain - ripping/tearing pain in 50%
    • Blood pressure variable
    • 1/3 no ECG find, ~40% no widened mediastinum
    • often associated with acute aortic regurgitation, myocardial ischemia, cardiac tamponade or hemopericardium, and hemothorax or exsanguination. Considerable (>20 mm Hg) variation in systolic blood pressure in the arms may be present. Descending thoracic aortic aneurysm is more commonly associated with splanchnic ischemia, renal insufficiency, lower extremity ischemia, or focal neurologic deficit due to spinal cord ischemia.
  25. Pulmonary Embolism
    • dyspnea, chest pain, hemoptysis, syncope; but usually more subtle
    • usu. nonspecific resp/hemodynamic manifestations
  26. STEMI Management
    • 1. PCI has greater 30 day mortality than thrombolysis (w/in 12 hrs is goal!)
    • 2. PCI can be used with CI to thrombolysis or in cardiogenic shock
    • 3. CI to thrombolysis: ICH, ischemic stroke w/in 3 mths, suspected aortic dissection, active bleeding
  27. 2nd degree Heart Block - Mobitz Type I
    progressive prolongation of the PR interval until a dropped beat occurs. Mobitz type I block can occur in the absence of heart disease, including in athletes and older adults; in patients with underlying heart disease, including acute ischemia; and in patients who are taking drugs that block the AV node, such as β-blockers (metoprolol), calcium channel blockers, and digoxin. This type of heart block is characteristically transient and usually requires no specific treatment; however, some patients may develop excessively slow heart rates and experience symptoms related to decreased cerebral or coronary perfusion
  28. 2nd degree Heart Block - Mobitz Type II
    regularly dropped beat (for example, a nonconducted P wave every second or third beat) without progressive prolongation of the PR interval. It is often associated with evidence of additional disease in the conduction system, such as bundle branch block or bifascicular or trifascicular block. Mobitz type II second-degree block suddenly and unpredictably progresses to complete heart block and is usually treated with a pacemaker.
  29. Chronic stable angina
    • Decrease myocardial demand
    • 1. Nitro
    • 2. Betablocker
    • 3. Calcium channel blocker

    Target 55-60bpm rest and 75% HR that produces angina
  30. Vascular protection
    • 1. ACEi
    • 2. Statin
    • 3. Aspirin
  31. Pulmonary Embolism
    chest pain and dyspnea in combination with the physical findings of asymmetric leg edema, elevated central venous pressure, tachypnea, and tachycardia
  32. Wolff-Parkinson-White
    • AV Reentrant Tachycardia
    • short PR interval and the presence of a delta wave, which signifies preexcitation
  33. Atrial Flutter
    negative sawtooth deflections in ECG leads II, III, and aVF, with a positive deflection in V1
  34. Multifocal atrial tachycardia
    characteristically occurs in the setting of chronic lung disease and is manifested by three or more P-wave configurations on the electrocardiogram with associated tachycardia
  35. Coronary revascularization indications
    angina pectoris refractory to medical therapy; a large area of ischemic myocardium and high-risk criteria on stress testing; high-risk coronary anatomy, including left main coronary artery stenosis or three-vessel disease; and significant coronary artery disease with reduced left ventricular systolic function

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