Cardiology review

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Cardiology review
2013-10-31 17:26:50

medicine shelf
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  1. Infective endocarditis in IV drug use
    • Staph aureus is the most common
    • Tricuspid valve involvement (right-sided) more common than aortic
    • Holosystolic murmur increases with inspiration = tricuspid involvement
    • septic pulmonary emboli
    • Heart failure more common in aortic valve involvement
  2. Acute atrial fibrillation
    • Cardiac: hypertension, acute ischemia, heart failure, myopericardial inflammation, valve disease, surgery
    • Pulmonary: acute lung disease (pneumonia), pulmonary emboli, hypoxia
    • Metabolic: Catecholamine surges, hyperthyroidism 
    • drug-related: alcohol, cocaine, amphetamines, theophylline
  3. Sinus bradycardia
    • physical conditioning
    • exaggerated vagal activity
    • sick sinus syndrome
    • hypoglycemia
    • medications (digitalis, beta-blockers, calcium channel blockers
  4. Sinus bradycardia
    symptomatic: treatments
    • dizziness, light-headedness, syncope, fatigue, worsened angina
    • Tx: intravenous atropine (decreases vagal input)
  5. Hypertrophic cardiomyopathy
    • carotid pulse dual upstroke
    • systolic ejection murmur along left sternal border
    • Murmur: increases as preload decreases (valsalva maneuver)
  6. Suspected aortic disection
    • Risk factors: Marfan syndrome, connective tissue disease, hypertension
    • Tearing chest/abdominal pain radiating to the back
    • Perfusion deficits (pulse deficit, >20mmHg blood pressure difference between right and left arm; aortic regurgitation murmur)
  7. Aortic disection
    • Chest X-ray or ECG (for other diagnosis)
    • Imaging: TEE, chest CT with contrast, MRI (only if nonemergency)
  8. Atrial fibrillation
    • ventricular rates as high as 150/min
    • Tx: beta blockers or calcium channel blockers (in hemodynamically stable patients)
    • digoxin; only in patients with AF due to heart failure (or those who can't tolerate BBs or CCBs)
    • cardioversion: only in patients who have had AF of <48hrs, or must receive rate control with 3-4 weeks anticoagulation
    • common complication of CABG (40% of patients)
    • tx of hemodynamically unstable (hypotension, AMS): immediate cardioversion
  9. hypertrophic cardiomyopathy
    • autosomal dominant
    • murmur decreases with increased pre-load
  10. Prinzmetal angina
    variant angina
    • coronary vasospasm
    • presentation: variant angina, typically at night; transient ST elevations on ECG
    • Risk factors: young females, smokers
    • Tx: calcium channel blockers or nitrites
  11. Cause of death in acute MI
    complex ventricular arrhythmias (i.e. reentry, such as vfib
  12. Cushing's syndrome
    • cortisol: vasoconstriction, insulin resistance, mineralocorticoid activity
    • result: high BPs, hyperglycemia, hypokalemia
    • proximal muscle weakness, central adiposity, thinning of the skin
  13. hypothyroidism
    weight gain, fatigue, bradycardia, depression, skin and hair changes
  14. COPD --> lower extremity edema
    • COPD leads to chronic hypoxemia --> vasoconstriction
    • pulmonary hypertension --> RV hypertrophy and failure
    • Right heart failure: elevated JVP, congestive hepatosplenomegaly, hepatojugular reflux, lower extremity edema
  15. arteriovenous fistula
    congenital vs acquired
    • Congenital: PDA, angiomas, pulmonary AVF, CNS AVF
    • Acquired: Trauma, iatrogenic (fem cath), atherosclerosis (aortocaval fistula), cancer
    • Complication: increases cardiac output through increased preload
    • signs: wide pulse pressure, strong peripheral arterial pulse, systolic flow murmur, tachycardia, flushed extremities
    • Dx: doppler ultrasonography
  16. high output heart failure 
    • AVMs or AVFs
    • thyrotoxicosis
    • Paget disease
    • anemia
    • thiamine deficiency
  17. aortic stenosis
    • increased intensity of apical impulse
    • narrow pulse pressure
    • typical systolic murmur
  18. venous insufficiency
    • normal jvp
    • dilated lower-extremity veins
    • worse with prolonged standing
    • pitting edema
    • skin discoloration
    • dermatitis/eczema
    • lipodermatosclerosis
    • skin ulceration
    • tx: leg elevation, exercise, compression stockings
  19. CHF symptoms
    • paroxysmal nocturnal dyspnea
    • DOE
    • peripheral edema
    • hepatomegaly
    • cardiomegaly
    • bilateral pleural effusion
    • third heart sound
  20. CHF
    causes in young individuals
    viral myocarditis: coxsackie B virus
  21. Secondary causes of hypertension
    • Renal parenchymal disease: elevated Cr, abnormal UA
    • Renovascular disease: severe HTN, recurrent flash pulmonary edema or resistant heart failure, abdominal bruit
    • Primary aldosteronism: easily provoked hypokalemia, slight hypernatremia, hypertension with adrenal incidentaloma
    • Pheochromocytoma: paroxysmal elevated blood pressures with tachycardia, pounding headache, palpitations, hypertension with adrenal incidentaloma
    • Cushing's syndrome: central obesity, facial plethora, proximal muscle weakness, abdominal striae, ecchymosis
    • Hypothyroidism: fatigue, dry skin, cold intolerance, constipation, weight gain
    • Primary hyperparathyroidism: hypercalcemia (polyuria, polydypsia), kidney stones, neuropsychiatric
    • COarctation of the aorta: differential hypertension with brachial femoral pulse delay
  22. subacute bacterial endocarditis
    viridans group streptococci, enterococci, and coagulase-negative staph (staph epidermidis)
  23. electrical alternans, sinus tachycardia
    • highly specific for pericardial effusion
    • can also see low voltages
  24. Pericarditis
    • infection: viral (most common), bacterial
    • Iatrogenic: surgery, trauma, radiation & drug-related
    • Connective tissue disease: RA, SLE
    • Cardiac: Dressler's syndrome (post-myocardial pericarditis), usually 1-6 wks after MI
    • Uremic: serum BUN >60mg/dL
    • Malignancy: cancer or treatemnt
  25. Statins
    • inhibit HMG-CoA reductase, rate limiting enzyme in the intracellular biosynthesis of cholesterol 
    • reduces serum LDL with minimal change in liver LDL
    • myalgias: 2-10% of patients, symmetric proximal muscle weakness or tenderness
  26. Thoracic aortic aneurysm
    • asymptomatic, or chest, back, flank, or abodminal pain
    • 60% are ascending aorta aneurysms
    • Ascending aortic aneurysms: associated with cystic medial necrosis or connective tissue disorders (Marfan, Ehlers-Danlos syndrome)
    • Descending: 40%, arise distal to the left subclavian artery. risk factors include hypertension, hypercholesterolemia, smoking
  27. most common cause of secondary hypertension
    renovascular hypertension
  28. renovascular hypertension
    suspect if...
    • elevated Cr >30% baseline after starting ACE inhibitor or ARB
    • Severe hypertension in pts with recurrent flash pulmonary edema
    • diffuse atherosclerosis
    • severe onset after age 55
    • asymmetric kidney size
    • abdominal bruit
  29. chagas disease
    • chronic protozoal disease caused by trypanosoma cruzi
    • megacolon/megaesophagus: destruction of the nerves controlling the GI smooth muscle
    • cardiac disease: prolonged myocarditis
  30. Digitalis toxicity
    • arrhythmia: Atrial tachycardia with AV block
    • slower atrial rate than atrial flutter (150-250)
    • increases vagal tone, decrease conduction through AV node = potentially causing AV block
  31. nitroglycerin
    • venodilatory effect
    • blood pools in the systemic venous circulation, decreasing the preload and left ventricular volume (decreases work of heart)
    • also cause some arterial vasodilation
  32. Lidocaine
    • class IB anti-arrhythmic drug
    • use: ventricular arrhythmias (v-tach)
    • decreases frequency of VPBs, but increases mortality in patients with acute MI
    • asystole, therefore not used prophylactically in patients with ACS
  33. Flecainide
    • Class IC antiarrhythmic: blocks sodium channels
    • elongates the period of depolarization
    • use: ventricular arrhythmias, SVTs (such as a-fib)
    • increases the QRS complex duration
  34. Thiazide diuretics
    side effects
    • decreased tolerance to glucose
    • increase LDL cholesterol
    • Increase plasma triglycerides
    • increase risk of acute gout arthritis (uric acid retention)
    • hyponatremia
    • hypokalemia
    • hypercalcemia
  35. constrictive pericarditis
    • elevated JVP with hepatojugular reflux
    • kussmaul's sign: lack of decrease or an increase in JVP on ispiration
    • pericardial knock
    • pericardial calcifications on chest radiograph
  36. pulsus paradoxus
    • >10mmHg fall in systolic pressure during inspiration
    • Ddx: cardiac tamponade, asthma, COPD
  37. hypertrophic cardiomyopathy
    • sx: 15-25% report syncope, chest pain on exertion
    • inheritance: autosomal dominant
    • murmur: systolic, left sternal border; worsens with maneuvers that decrease preload
    • complication: diastolic heart failure
    • Tx: beta blockers, CCB if patient cannot tolerate beta blocker
  38. wide complex tachycardias
    • AV dissociation, Fusion/capture beats: Ventricular tachycardia
    • -stable: IV amiodarone

    • No AV dissociation: SVT with aberrancy
    • -Stable: Maneuvers to determine rhythm (carotid massage, rate control)

    • Unstable: hypotension, AMS, respiratory distress
    • - synchronized cardioversion
  39. Sustained monomorphic ventricular tachycardia
    • occurs 6 to 48 hours post MI
    • tx in stable: antiarrhythmics (amiodarone, lidocaine, procainamide)