IM cardio

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Author:
TerryZ
ID:
241406
Filename:
IM cardio
Updated:
2013-11-27 09:39:44
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internal medicine IM cardiology cardio
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IM
Description:
Internal Medicine - cardiology
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  1. Coronary artery disease
    RFs
    DM (worst), HLipid, HTN, Smoking, Age (M>45, W>55), FHx of premature CAD/MI, vHDL
  2. Stable angina pectoris
    Prognosis
    • LV fn (EF) < 50%
    • L main coronary artery (2/3 of heart)
    • two or three-vessel CAD
  3. Stress echocardiography
    What it accomplishes
    • Detects ischemia via wall motion abnormalities
    • Assesses LV size/fn
    • Dx valvular dz
    • ID CAD in presence of preexisting abnormalities
    • If (+), do cardiac catheterization
  4. Stable angina pectoris
    Pain does NOT change with...
    • Breathing
    • Body position
    • No chest wall tenderness
  5. Ways to rescue areas of reversible ischemia
    • PCI
    • CABG
  6. PCI
    • percutaneous coronary intervention
    • consists of:
    •   coronary angioplasty via balloon
    •   stenting
    • equally effective as CABG
    •   Higher freq of revasc with stent
  7. Pharmacologic stress test options
    • IV adenosine + dipyridamole
    •   generalized coronary vasodilation
    • Dobutamine
    •   ^myocard O2 demand via ^HR, BP, contractil
    • + Thallium - decreased uptake during exercise
  8. Cardiac catheterization
    • Info on hemodyn, pressure, CO, O2 sat, etc.
    • Indic: (+) stress test; nondiagn; angina cont; 
    •    severe sx; valv dz; surg?
  9. Coronary arteriography (angiography)
    • Most accurate ID presence/severity of CAD
    • Std test for delineating coronary anatomy
    • Determine if revascularization needed
    • Stenosis >70% can produce angina
  10. Stable Angina - Medical TXs
    • aspirin & risk factor mod: (vMorb, MI)
    • beta blockers: (atenolol, metoprolol)
    • nitrates: nitrates
    • CCBs: secondary
    • ACEi & diuretics: if CHF
    • revascularization: ^risk - PCI, CABG
  11. Stable angina - TX guidelines
    • All: aspirin & risk factor modifications
    • Mild: (nl EF, mild ang, 1vsl) nitr, BB, ?CCB
    • Mod: (nl EF, mod ang, 2vsl) ?+angiography
    • Sev: (v EF, sev ang, 3 or L) CABG
  12. CAD - TX
    • hospital admission w/ continuous cardiac mon
    • IV access, supplemental O2 (if hypoxic)
    • Pain cntl w/ nitrates and morphine
    • aspirin, clopidigrel, BB, LMWH, nitrates
    • IIb/IIIa inhib as adjuncts (PTCA/stenting)
    • Cardiac catheterization/revascularization
    • Post acute: ASA/~platelet, BB, nitrates; RFs
  13. Acute MI - Dx
    • ECG: ^T, ST/->Q->~T, ST
    • Card Enz:
    • Marker   /        ^        
    • CK      6-12h   18hr     2-3d
    • CK-MB 3- 6h 12-24h 12-48h
    • CTn-I  3-12h 12-24h  7-10d
    • CTn-T 3-12h 12-24h 10-14d
    • STEMI^; NSTEMI ~ST/
  14. Acute MI - tx
    • Init: ASA, BB, ~thromb<12h(gIIb/IIIa,UFH), P;
    • Post: ASA, BB, statins, ACEI
    • Other: nitrates, O2
    • Revasc: PCI (<90m); thromb (<24h); CABG
  15. Variant or Prinzmetal's angina
    • def: transient coronary vasospasms
    • occ: episodes at rest, at night, v-dysrhythm
    • hallmk: transient ST/ (angiogr IV ergonovine)
    • tx: CCB ?LA NO3; NOT BBs!, RF mod
  16. EKG lead associations
    • Ant: V1-4
    • Post: V1-2 (inv)
    • Lat: I, aVL, V5, V6
    • Inf: II, III, aVF
  17. Acute pericarditis - causes
    • Idiopathic: probably post-viral
    • Infectious: V (cox, echo, adeno, EBV, flu, HIV, HAV, HBV), B (TB), F (toxo)
    • Acute MI: 1st 24 hrs
    • Uremia: -
    • Collagen vascular dzs: SLE, sclero, RA, sarc
    • Neoplasm: Hodgkin lymphoma, breast/lung CAs
    • Drug-induced lupus: procainamide, hydralazine
    • Post-MI: Dressler's syndr (weeks-months)
    • Post surg: postpericardiotomy syndrome
    • Misc: Amyloidosis, Radiation, Trauma
  18. Acute pericarditis - prognosis
    • Most pts recover w/in 1-3 weeks
    • Complicat'ns: pericard'l effus'n, card tampon'de
  19. Acute pericarditis - Sx
    • CP: severe, pleuritic, w/breathing; retrosternal & L precordial rad to trapezius ridge & neck; positional ^supine, cough, swallow, deep inspir; vSitting up, leaning forward. ~P rheumatoid
    • F & leukocytosis: .
    • Pericardial friction rub: (specific) scratching, hi-pitched sound (a-systole, v-systole loudest, early diastole) heard best during expiration sitting up, comes and goes over several hours
  20. Acute pericarditis - Dx
    • ECG shows 4 changes in sequence:
    • 1: Diffuse ST elevation & PR depression
    • 2: ST segment->nl (1 week)
    • 3: ? T wave inverts
    • 4: T wave returns to nl
    • Echo if PC w/ effusion suspected (often nl)
  21. Acute pericarditis - Tx
    • Most cases self-limited (2-6 weeks)
    • Tx underlying cause if known
    • NSAIDs mainstay of tx; colchicine
  22. Constrictive pericarditis - etiology
    • Fibrous scarring of pericardium->rigidity/thick w/ obliteration of pericardial cavity
    • Fibrotic, rigid pericardium diastolic filling
    • Ventricular filling unimpeded in early diastole
    • Ventricular filling abruptly stops at limit
    • MC idiopathic; uremic, rad, TB, chron PC effus, tumor, connective tissue d/o, prior surg
  23. Constrictive pericarditis - S/Sx
    • Appears ill;
    • Presents: vol overload sxs or CO
    • JVD, Kussmaul's sign (JVD ~ w/inspir), pericardial knock (early diast fill sound after S2), ascites, dependent (pedal) edema, tender hepatomegaly, x pulsus paradoxus
  24. Constrictive pericarditis - Dx
    • ECG: (non-specif) QRS v, T flat/inv, L atr abnl,  aFib (adv, <.5)
    • Echo: /periph thickness (.5), sharp halt ventr fill, atrial enlargement
    • CT/MRI: ? pericardial thickening/calcifications
    • CXR: clear lungs, nl-slightly /<3, PC calcif'n
    • Cath: /&= diastolic all chambers; vent tracing show rapid y descent (square root sign)
  25. Constrictive pericarditis - Tx
    • Underlying condition
    • Diuretics to alleviate fluid overload sx
    • Monitor/treat for any coagulopathy
    • Surg strip/remove both layers of constricting PC
  26. Pericardial effusion
    • defn: Pericarditis->exudate (//->tamponade)
    • etiol: CHF, cirrhosis, nephrotic syndr
    • s/sx: muffled <3 sounds, soft PMI, dull lung base, ?pericardial friction rub
    • dx: echo, CXR (>250ml, watter bottle), ECG (QRS v, T flat), CT/MRI(?), fluid analysis
    • tx: depends on hemodynamic stability; pericardiocentesis iff tamponade; small - 1-2wk
  27. Cardiac tamponade
    • Def: Pericardial effusion that mechanically impairs diastolic filling of the heart; elevation & equalization intra-cardiac/pericardial pressures
    • Rate: of accumulation (fast 200mL, slow 2L)
    • Cause: penetr trauma, iatrog, pericard, post-MI w/ free wall rupture
    • S/sx: /JVP, ><pulse press, pulsus paradoxus (weak inhale/strong exhale), muffled HS, cardiogenic shock (tachyp, tachyc, HoTN)
    • Dx: echo, CXR, ?ECG, cath (pressure eq)
    • Tx: Non-hemorrh - stable--monitor, RF-dialysis; unstable--pericardiocentesis, fluid challenge. Hemorrh - emergent surgery
  28. Endocarditis - types
    • Acute
    • Subacute
    • Native valve
    • Prosthetic valve
    • IV Drug
  29. Acute endocarditis - cause & prognosis
    • MC cause: Staph aureus on normal heart valve
    • Prognosis: Death in < 6 weeks untreated
  30. Subacute endocarditis - cause & prognosis
    • Cause: Strep viridans, Enterococcus on damaged heart valve
    • >6 weeks for death
  31. Endocarditis in IV drug users
    • R-sided
    • Staph aureus, enterococci, strep
    • Candida, Pseudomonas
  32. Endocarditis diagnosis - imaging
    TEE > transthoracic echocardiography
  33. Endocarditis - dx criteria
    • Duke Criteria (2 maj, 1 maj + 3 min, 5 min)
    • Major criteria: sustained bacteremia, Endocardial involvement
    • Minor criteria: predisposing cond, F>38C, vascular phenom, immune phenom, (+) blood culture, (+) echo
  34. Endocarditis - tx
    • Parenteral abx 4-6 weeks
    • -cx but ^suspicion: Pen/Vanc + aminogycoside
    • Empiric
    • -native valve: PenG/Amp + Nafc/Oxac + Gent
    • -IV drug user: Vanc
    • -Prosthetic vlv: Vanc + Gent + Rifamp
  35. Cardiomyopathy types
    • Dilated MC: insult causes dysfn of L ventricle contractility
    • Hypertrophic: inherit, diastolic dysfn; stiff, hypertroph ventricle
    • Restrictive (rare): infiltr of myocard->V ventricular compliance
  36. Dilated cardiomyopathy - causes
    • 50% idio
    • CAD
    • toxic (EtOH, doxyrub)
    • Metabol (thiam/Se defic, HoPO4, uremia)
    • infect (viral, Chagas, Lyme, HIV)
    • Thy dz (Ho/H)
    • Peripartum
    • Colagen vasc dz (SLE, scleroderma)
    • ->tachy
    • catechol induced (pheo, cocaine)
    • familial/genetic
  37. Dilated cardiomyopathy - clinical
    • s/sx: L&R CHF
    • Ht sounds: S3, S4, mitral/tricusp insuff murmurs
    • Cardiomegaly
    • Arrythmia: coexisting
    • Sudden death
    • Asympt: until HF
  38. Cardiomyopathy - dx by type
    • Dilated: ECG, CXR, Echo (CHF); fam hx DCM
    • Hypertrophic: Echo; clinical/fam hx
    • Restrictive: Echo (thick myocard, ^R/L atrium), ECG (vVolt, conduct abnl, arrhyth/afib, endomyocardial bx (amyloid apple)
  39. Cardiomyopathy - tx by type
    • Dil: ~CHF digox,diur,vasodil,xplant;ICD; anticoag
    • HTroph: x exer; BB(CCB), diur, myomectomy
    • Restr: tx disorder

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